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Case Report Forms

These forms should ONLY be used by Local Health Department staff during a case investigation. Citizens wishing to report the occurrence of a communicable disease should consult their Local Health Department by phone. Data collected on these forms should help determine if cases meet the appropriate CDC case definitions

Disease / Condition specific forms
Anthrax pdf Malaria
Babesiosis pdf documemnt Measles
Botulism pdf documemnt Meningitis (Aseptic)
ms word logo Meningitis (Aseptic)
Botulism Infant pdf documemnt Meningitis (Bacterial)
Brucellosis pdf documemnt Meningococcal Disease
Cholera and Other Vibrio Illnesses pdf documemnt Mumps (Updated)
Cryptosporidiosis Supplement Outbreak (See below)
Cyclospora pdf document Perinatal Hepatitis B
Data and Specimen Handling (DASH) pdf document Perinatal Hepatitis B Contact
Dengue pdf document Pertussis
Diphteria pdf document Pneumonia- Health Care Worker
Encephalitis
ms word logoEncephalitis 		pdf documentPolio

Escherichia coli 0157:H7

 pdf document Psittacosis
Gastroenteritis Illness pdf document Q-Fever
Haemophilus Influenzae pdf document Rickettsial (RMSF/Ehrlichiosis)
Hansen's Disease (Leprosy) pdf document Rocky Mountain Spotted Fever
Hantavirus pdf document Rubella
Hepatitis (Viral) pdf document Rubella - Congenital
ms word logoHepatitis C (Initial) pdf document SARS

ms word logoHepatitis C (Supplemental)

 pdf document Smallpox

pdf Influenza A(H1 N1) Novel Influenza Case Report Form

 pdf document Tetanus

pdf Influenza A (DHMH Testing Scheme)

 pdf document Toxic Shock Syndrome
pdf Influenza-Associated Pediatric Death pdf document Trichinosis

pdf Kawasaki Syndrome Printable

 pdf document Tularemia
pdf Kawasaki Syndrome Fillable pdf document Typhoid and Paratyphoid Fever
pdf Legionellosis - CDC pdf document Vaccine Adverse Event Reporting System(VAERS)
pdf Legionellosis - DHMHSupplemental pdf document Varicella
pdf Leptospirosis

pdf document Varricella Death Investigation
pdf Leprosy pdf document Varicella Death Guidelines
pdf Listeria pdf document Vibrio
pdf Lyme Disease
ms word logo Lyme Disease
 pdf document West Nile Virus
worddocument West Nile Virus
   

Outbreak Final Report Forms

Long-Term Care Facility Forms

Adobe
Acrobat

Microsoft
Word

Gastroenteritis Outbreak

PDF

Word

Respiratory Outbreak

PDF

Word

Scabies Outbreak

PDF

Word

Drug Resistant Organism Outbreak

PDF

Word
     
Foodborne Outbreak Forms    
     
Investigation of a Foodborne Outbreak Form PDF Word
Guidelines for Completing “Foodborne Outbreak” Form PDF Word
E coli 0157:H7 Outbreak Surveillance Report Form PDF  
     
Other Forms    
     

Daycare Facility Outbreak

PDF

Word

Hospital Outbreak (Excluding Gastroenteritis)

PDF

Word

Gastroenteritis Outbreak at a Hospital

PDF

Word

Pertussis Outbreak

PDF

Word

School Outbreak

PDF

Word

Waterborne Illness Outbreak

PDF

Word
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